Nutrition Questionnaire

Nutrition Questionnaire

Please fill out as many of the following questions you are comfortable answering. Please be as detailed as possible as it will help Betsy created a more tailored program that addresses your needs and goals.

1Contact Info

2Your Goals and Challenges

3Basic Information

4Diet

5Exercise and Stress Management

6Doctor Notification Preference

Survey date

Salutation

First name

Last name

Email*

Cell phone

Home phone

Best time to reach you

Please indicate the best days and times to do your nutrition consult with Betsy. We'll contact you to schedule a time from there.

Address 1

Address 2

City

State

Zip Code

Who referred you to Sunshine Wellness (Betsy Markle RD)?

Which SWI services are you interested in?

Consulting

Detox

Workbook

GI Testing

Supplement Program

Nutrition Package Details

Other

Describe the goals you hope to accomplish with Betsy

What are the limiting factors that may hinder you from reaching your wellness goals?

Lack of Time

Crazy Schedule

Lack of Motivation

Lack of Knowledge

Mate influences me with bad habits

Significant health problems

Other

Describe the 'other' limiting factors

Which of the following are chronic symptoms for you?

Anxiety/Depression

Asthma

Arthritis

Cancer

Chronic Fatigue

Constipation

Eating Disorder

Excess Weight

Headaches

Heartburn

Heart Disease

High Blood Pressure

Loose Bowels

Menopause

PMS

Osteoporosis

Skin Problems

Sleep Problems

Thyroid Imbalance

Yeast Infections

Other

Other symptoms

Rate your chronic symptoms in order of significance

Please list your top 5. #1 being the most significant.

List any medications you take

List any supplements you take

Age

Occupation

Marital status

How many children do you have?

If you have children under 18, please list their ages and names.

Do you have children under the age of 18?

Please fill in one row for each child

First Name

Age

Gender

What is your height?

Feet

Inches

What is your current weight?

Please describe your weight history

Please include details about regular and/or occasional fluctuations as well as information about weight loss or gain milestones

For each item below, please add the time you normally do it and what you consume at that time.

Wake time

Typical Breakfast + Time

Typical Lunch + Time

Typical Dinner + Time

Bed time

Typical Snacks + Times

Who is the primary food shopper?

Who is the primary household chef?

Where do you usually food shop?

Provide details for three staple meals that you prepare at home

On average, how many times do you eat out each week?

What types of restaurants do you eat at?

Describe some typical meals that you eat when you dine out.

How many cups of water do you drink per day?

Do you drink milk?

Yes

No

What kind and how many glasses per day?

Do you drink juice?

Yes

No

What kind and how many glasses per day?

Do you drink caffeinated coffee?

Yes

No

How many cups per day? What size?

Do you drink caffeinated tea?

Yes

No

How many cups per day?

Do you drink diet soda?

Yes

No

How many per day?

Do you drink soda or energy drinks?

Yes

No

How many per day and what kind?

Do you drink alcohol?

Yes

No

What kind and how much?

Do you consume tobacco?

Yes

No

How much per day and what kind?

Do you use artificial sweeteners?

Yes

No

What kind and how often?

Do you consume sugary foods?

Yes

No

What kind and how much?

Do you exercise on a regular basis?

What is your typical weekly exercise routine? Please include types of exercise, duration and how many times per week.

If it is easier, you can just write out your exercise plan.

Do you consider your life to be stressful?

Describe your sources of stress?

Do you handle your stress well?

What techniques do you use to manage your stress?

Do you get 7-8 hours of uninterrupted sleep per night?

What prevents you from getting that much sleep?

Is there anything else we should know before we get started?

Would you like us to notify your doctor of your new nutrition plan?

Doctor's name and contact info

Untitled

Email

This field is for validation purposes and should be left unchanged.

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Client Feedback

People always ask how I lost 65 pounds and how I am maintaining it. It hasn’t been an easy journey but Betsy’s Workbook sums it up perfectly. Nutrition Simplified is an invaluable resource for anyone who wants to lose weight properly and keep it off. For busy moms like me, my favorite parts are the simple food shopping guides and meal ideas.

Nutrition Simplified Workbook is my travel companion at home and work because I use the nutrition resources and guides daily. Betsy’s program makes it effortless to stay on track. Her 7 steps are easy to follow and all the information is spelled out clearly so there is no longer any mystery about my diet and nutrition. Betsy’s expertise and her workbook have changed my life dramatically in just 4 weeks. Thank you Betsy!

As a Spa Director, I have access to the latest and greatest health and wellness products. The best discovery for me this year was Sunshine Wellness. Betsy’s Detox Programs are based on solid science which is very important to me. I was also impressed with how easy the detox was to follow (loved the shopping list and recipes). I was delighted to discover that I had more energy than usual and I was never hungry – not even at night which tends to be a tough time for me.

Working with Betsy has changed my life. When I follow the nutrition and supplement plan that she has developed for me, I feel energized, healthy, and in control. So far, I have lost 30 pounds! I LOVED Betsy’s 9-Day Detox! I was hesitant to try it because I have occasional low blood sugar but I felt completely satisfied. Having a set meal plan and shopping list made cooking so easy.

I am eternally grateful for Betsy’s expertise. Through nutritional consulting and GI testing, we determined I was intolerant to gluten and other foods I had been eating regularly. Within a short period of time, I started losing weight, lost my severe sugar addiction, and became comfortable with food again. My blood sugar has stabilized and I have a lot more energy. I am finally in control and have my body back. Betsy has always been kind, non-judgmental, and very knowledgeable – thank you for all your support!

I have just completed the 9 Day Detox Program that Betsy designed for the second time. As a woman who is passionate about clean diet and exercise, it’s amazing how much better I feel during and after this detox program. Betsy’s sample menu, recipe ideas, shopping list, great tasting shake, and her support make this the best detox around! Her support and care for you as an individual sets her apart from any health professional or nutritionist that I have ever met.

In my opinion, Betsy is the new shining star in my life (& in our community). I attended one of her meal-planning workshops recently and followed it up with a complete revamping of my pantry and refrigerator. She also visited my Sport Psychology class at FIT, speaking to the many student athletes. They were completely engaged in her presentation. The thing I love most about Betsy is that she seems to GLOW with health, the best testimony of all to her expertise. When you meet with her for your first session, you will know what I mean. A treasure found!

I have had the pleasure of working with Betsy for over five years. She has demonstrated an incredible passion for being a Registered Dietitian and is a visionary in the health and wellness industry. Her talent to connect with individuals and her attention to detail, as seen in her workbook, are some of the reasons why I will always refer clients to Betsy.

Betsy is a realistic nutritionist and that makes her programs very achievable. Her workbook is excellent! It is comprehensive yet simple to follow. I have given her book to many of my patients because the information helps them heal faster. And, I had a great experience with her detox program. I have changed many of my eating habits based on Betsy’s workbook and detox program. I highly recommend her!

I needed an easy to follow nutrition program that virtually guaranteed my success. During Betsy’s 9 Day Detox Program, I lost 8 pounds (and that was without exercising – through diet only!). I no longer have cravings for sweets and I now eat only what my body needs. Even one month after the program, I don’t binge eat or yearn for sugar. As a Chiropractor, I highly recommend Betsy’s program.

From my experience with Betsy Markle, I have gained more knowledge through her newsletters, detox ceremonies, and recipes than I have in my years of research. She is knowledgeable and up to date with all of her information. Her realistic guidelines make it easy to transition to engage in more nutritious eating habits. I have tried various recipes from her website and have yet to have a bad experience. I look forward to her monthly newsletters, and am grateful to have found such a great source of data with the many questionable resources available today. I will be referring to Sunshine Wellness for years to come!

I eat pretty healthy but Betsy’s detox program helped me take my body and nutrition habits to another level. One of my favorite benefits is my allergy relief. I have always suffered from allergies & would have to take medication to get through the spring and fall…I have not taken any allergy medicine since I did the detox. Betsy’s detox programs are easy and enjoyable to follow because the menu, recipe ideas and shakes are delicious.